Incident and Accident Investigation Forms

Document Number: HSF-11.3

PART A – INCIDENT DETAILS:

(To be completed for all incident types)
OPERATION:.............................................................................................................................................................................................

1.  NAME OF INJURED/AREA/VEP: .............................................................. 2.  CO ID. NO: ....................................................................

3.  NATIONAL ID NO: ................................................................................... 4.  DATE OF BIRTH: ............................................................
5.  DATE EMPLOYMENT COMMENCED: ...................................................................................................................................................
6.  DESIGNATION: ........................................................................................7.  DATE OF INCIDENT:........................................................
8.  TIME OF INCIDENT: ................................................................................ 9.  PLACE OF INCIDENT: .....................................................
10.  CLASS OF INCIDENT:
F LTI FA NM VEP EI EMI
NB: If NM, VEP, EI or EMI is marked, questions 11, 12 and 13 do not have to be completed
11.  PART OF BODY AFFECTED:
Head or neck Eye Trunk Finger Hand

Arm Foot Leg Internal Multiple

12.  TYPE OF INJURY:
Sprains or strains Poisoning Fractures Burns

Occupational disease Asphyxiation Unconsciousness Amputation

Contusions or wounds Electric shock Any other (specify): …………………..

13.  EXPECTED PERIOD OF DISABLEMENT:
0–3 3–7 1–2 2–4 1–6
KILLED
DAYS DAYS WEEKS WEEKS MONTHS
14.  DESCRIPTION OF OCCUPATIONAL DISEASE: .....................................................................................................................................
15.  MACHINE/PROCESS INVOLVED/TYPE OF WORK PERFORMED/EXPOSURE:
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................

HSE PROGRAMME MANAGER’S NAME: ..................................................................................................................................................

SIGNATURE: ...................................................................................................... DATE: ..........................................................................
Incident No: (To be allocated by Senior HSE Manager)

REPORT DISTRIBUTION (tick appropriate boxes)

Operations Manager CEO
Senior HSE Manager Finance Department
HR Department Engineering Department
Other (specify): ........................................................................................................................................................................

Page 1 of 8
UNCONTROLLED Classification: Proprietary Author: JMZ de Wet
Approved by: JMZ de Wet Approval Date: 30/01/2020 Revision number: 2020-00
All printouts marked “UNCONTROLLED” are valid only for 3 days from this date - 08/05/2020
 Incident and Accident Investigation Forms
Document Number: HSF-11.3

PART B – NEAR-MISS INVESTIGATION:

(To be completed for NM incidents only)
OPERATION:.............................................................................................................................................................................................
1. NAME OF PERSON INVOLVED/AREA/VEP:........................................................................................................................................
2. DATE AND TIME OF INCIDENT:..........................................................................................................................................................
3. BRIEF DESCRIPTION OF INCIDENT:
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
4. CAUSE OF INCIDENT:
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
5. RECOMMENDATIONS TO PREVENT RE-OCCURRENCE: (To be completed by HSE Programme Manager and approved by Operations
Manager)
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................

6. RECOMMENDATIONS APPROVED BY PROJECT MANAGER: YES NO

7 RECOMMENDATIONS IMPLEMENTED: YES NO

8. IF NOT IMPLEMENTED, WHY:

.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
9. IF STILL TO BE IMPLEMENTED, STATE EXPECTED DATE OF COMPLETION: .......................................................................................
HSE PROGRAMME MANAGER’S NAME:...................................................................................................................................................
SIGNATURE: ...................................................................................................... DATE: ..........................................................................
OPERATIONS MANAGER’S NAME: ...........................................................................................................................................................
SIGNATURE: ...................................................................................................... DATE: ..........................................................................

Page 2 of 8
UNCONTROLLED Classification: Proprietary Author: JMZ de Wet
Approved by: JMZ de Wet Approval Date: 30/01/2020 Revision number: 2020-00
All printouts marked “UNCONTROLLED” are valid only for 3 days from this date - 08/05/2020
 Incident and Accident Investigation Forms
Document Number: HSF-11.3

PART C – INVESTIGATION OF INCIDENT:

(To be completed only for fatal (F), lost time (LTI) and first-aid cases (FA))
OPERATION:.............................................................................................................................................................................................
1. NAME OF PERSON INVOLVED/AREA/VEP:........................................................................................................................................
2. DATE AND TIME OF INCIDENT:..........................................................................................................................................................
3. DESCRIPTION OF INCIDENT: (To be completed by the injured person’s immediate Supervisor)
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
NAME:............................................DATE:.............................................TIME: ....................SIGNATURE:................................................

4. SAFETY REPRESENTATIVE’S INCIDENT INVESTIGATION REPORT: (To include details of what, when, where and why the incident occurred)
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
NAME:............................................DATE:.............................................TIME: ....................SIGNATURE:................................................

5. HSE PROGRAMME MANAGER’S COMMENT: (To make comment on what in HIS/HER opinion caused the incident and what will be done to
prevent a re-occurrence)
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
NAME:............................................DATE:.............................................TIME: ....................SIGNATURE:................................................

6. OPERATIONS MANAGER’S COMMENT: (To make comment on what in HIS/HER opinion caused the incident and what will be done to
prevent a re-occurrence)
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
NAME:............................................DATE:.............................................TIME: ....................SIGNATURE:................................................

7. ENGINEERING MANAGER’S COMMENT: (To make comment on what in HIS/HER opinion caused the incident and what will be done to
prevent a re-occurrence)
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
NAME:............................................DATE:.............................................TIME: ....................SIGNATURE:................................................

8. SUSPECTED CAUSE OF INCIDENT: (To include all potential, contributory and root causes and completed by HSE Operations Manager)
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
NAME:............................................DATE:.............................................TIME: ....................SIGNATURE:................................................
8. RECOMMENDED STEPS TO PREVENT A RE-OCURRENCE: (To be completed by Senior HSE Manager and approved by Operations Manager)
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................

Page 3 of 8
UNCONTROLLED Classification: Proprietary Author: JMZ de Wet
Approved by: JMZ de Wet Approval Date: 30/01/2020 Revision number: 2020-00
All printouts marked “UNCONTROLLED” are valid only for 3 days from this date - 08/05/2020
 Incident and Accident Investigation Forms
Document Number: HSF-11.3

NAME:............................................DATE:.............................................TIME: ....................SIGNATURE:................................................

9. ACTION COMPLETION DATE:............................................................................................................................................................

OPERATIONS MANAGER’S NAME:......................................................... APPROVED: YES NO

OPERATIONS MANAGER’S SIGNATURE:.................................................TIME: ...................................................DATE: ..........................

PART D – VEHICLE/EQUIPMENT/PROPERTY DAMAGE INVESTIGATION:

(To be completed for vehicle/equipment/property damage (VEP) incidents only)
OPERATION:.............................................................................................................................................................................................
1. DATE AND TIME OF INCIDENT:..........................................................................................................................................................
2. VEHICLE/EQUIPMENT/PROPERTY DESCRIPTION:..............................................................................................................................
.................................................................................................................................................................................................................
3. VEHICLE/EQUIPMENT REGISTRATION/SERIAL NUMBER:..................................................................................................................
4. NUMBER OF VEHICLES/EQUIPMENT INVOLVED:..............................................................................................................................
5. OPERATOR’S NAME:.........................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
6. IF APPLICABLE, NAMES AND CONTACT NUMBERS OF OUTSIDERS INVOLVED:.................................................................................
.................................................................................................................................................................................................................
7. PROPERTY LOCATION:.......................................................................................................................................................................
8. ESTIMATED COST OF DAMAGE:........................................................................................................................................................
9. ESTIMATED PERIOD OUT OF SERVICE:..............................................................................................................................................
10. BRIEF DESCRIPTION OF INCIDENT:....................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
11. CAUSE OF INCIDENT:........................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
12. RECOMMENDATIONS TO PREVENT RE-OCCURRENCE: (To be completed by HSE Programme Manager and approved by Operations
Manager)
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
HSE PROGRAMME MANAGER’S NAME:.................................................DATE:.....................SIGNATURE:................................................
13. ACTION COMPLETION DATE:............................................................................................................................................................

OPERATIONS MANAGER’S NAME:......................................................... APPROVED: YES NO

OPERATIONS MANAGER’S SIGNATURE:................................................................................ DATE:................................TIME:...............

Page 4 of 8
UNCONTROLLED Classification: Proprietary Author: JMZ de Wet
Approved by: JMZ de Wet Approval Date: 30/01/2020 Revision number: 2020-00
All printouts marked “UNCONTROLLED” are valid only for 3 days from this date - 08/05/2020
 Incident and Accident Investigation Forms
Document Number: HSF-11.3

PART E – ENVIRONMENTAL INCIDENT (EI) INVESTIGATION:

(To be completed for environmental incidents (EI) only)
OPERATION:.............................................................................................................................................................................................
1. DATE AND TIME OF INCIDENT:..........................................................................................................................................................
2. LOCATION OF INCIDENT:...................................................................................................................................................................
3. BRIEF DESCRIPTION OF INCIDENT:
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
4. ACTIONS TAKEN TO CLEAN UP THE ENVIRONMENT:
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
5. CAUSE OF INCIDENT:
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
6. ACTIONS TAKEN TO PREVENT A RE-OCURRENCE:
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
7. ESTIMATED COST OF CLEAN UP:.......................................................................................................................................................
HSE PROGRAMME MANAGER’S NAME:.................................................DATE:.....................SIGNATURE:................................................

OPERATIONS MANAGER’S NAME:......................................................... APPROVED: YES NO

OPERATION MANAGER’S SIGNATURE:................................................... DATE:...............................................................TIME:...............

Page 5 of 8
UNCONTROLLED Classification: Proprietary Author: JMZ de Wet
Approved by: JMZ de Wet Approval Date: 30/01/2020 Revision number: 2020-00
All printouts marked “UNCONTROLLED” are valid only for 3 days from this date - 08/05/2020
 Incident and Accident Investigation Forms
Document Number: HSF-11.3

Page 6 of 8
UNCONTROLLED Classification: Proprietary Author: JMZ de Wet
Approved by: JMZ de Wet Approval Date: 30/01/2020 Revision number: 2020-00
All printouts marked “UNCONTROLLED” are valid only for 3 days from this date - 08/05/2020
 Incident and Accident Investigation Forms
Document Number: HSF-11.3

PART F – EQUIPMENT AND MACHINERY FAILURE (EMF) INVESTIGATION:

(To be completed for equipment and machinery failure incidents (EMF) only)
OPERATION:.............................................................................................................................................................................................
1. DATE AND TIME OF INCIDENT:..........................................................................................................................................................
2. LOCATION OF INCIDENT:...................................................................................................................................................................
3. BRIEF DESCRIPTION OF INCIDENT:
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
4. ACTIONS IN PLACE TO HAVE PREVENTED THE INCIDENT IN THE FIRST INSTANCE:
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
5. CAUSE OF INCIDENT:
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
6. ACTIONS TAKEN TO PREVENT A REOCURRENCE:
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
7. ESTIMATED COST OF INCIDENT:.......................................................................................................................................................
HSE PROGRAMME MANAGER’S NAME:.................................................DATE:.....................SIGNATURE:................................................

OPERATIONS MANAGER’S NAME:......................................................... APPROVED: YES NO

OPERATIONS MANAGER’S SIGNATURE:................................................................................ DATE:................................TIME:...............

Page 7 of 8
UNCONTROLLED Classification: Proprietary Author: JMZ de Wet
Approved by: JMZ de Wet Approval Date: 30/01/2020 Revision number: 2020-00
All printouts marked “UNCONTROLLED” are valid only for 3 days from this date - 08/05/2020
 Incident and Accident Investigation Forms
Document Number: HSF-11.3

PART G – SENIOR HSE MANAGER RESPONSIBILITY:

OPERATION:.............................................................................................................................................................................................
1. DATE OF INCIDENT:...........................................................................................................................................................................
2. INCIDENT NO:...................................................................................................................................................................................
3. SENIOR HSE MANAGER’S COMMENT:
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................

4. IS FOLLOW UP REQUIRED: YES NO

5. IF YES, WHAT MUST BE DONE?

.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................

6. HAVE THE STATISTICS BEEN RECORDED? YES NO

7. IF NO, WHY?
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................

8. ARE ANY ADDITIONS OR AMENDMENTS REQUIRED IN TERMS OF THE YES NO

HEALTH AND SAFETY MANAGEMENT SYSTEM?

9. IF YES, LIST ADDITIONS OR ALTERATIONS:

.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
NAME:.................................................................DATE:....................................SIGNATURE:..................................................................

Page 8 of 8
UNCONTROLLED Classification: Proprietary Author: JMZ de Wet
Approved by: JMZ de Wet Approval Date: 30/01/2020 Revision number: 2020-00
All printouts marked “UNCONTROLLED” are valid only for 3 days from this date - 08/05/2020